I-914a Frm Toc

TABLE OF CHANGES – FORM

Supplement A to Form I-914, Application for Family Member of T-1 Recipient

OMB Number: 1615-0099

02/17/2021

Reason for Revision: Revision

Project Phase: 60 Day

Legend for Proposed Text:

• Black font = Current text

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Expires 04/30/2021

Edition Date 10/02/2020

Current Page Number and Section	Current Text	Proposed Text
Page 1, To Be Completed by Attorney or Representative, if any	[Page 1] To Be Completed by Attorney or Representative, if any Fill in box if G-28 is attached to represent the applicant. ATTY State License #	[Page 1] To be fully completed by an attorney or accredited representative, if any. Select this box if Form G-28 is attached. Attorney State Bar Number Attorney or Accredited Representative USCIS Online Account Number
Page 1, PART A. Family Member Relationship to You (the principal)	[Page 1] START HERE - Type or print. Use black ink. See Instructions for information about eligibility and how to complete and file this application. The recipient of the T nonimmigrant classification is referred to as the principal applicant. His or her family member(s) is referred to as a derivative applicant. Form I-914, Supplement A, is to be completed by the principal applicant. PART A. Family Member Relationship to You (the principal) The family member that I am filing for is my: (Check one) Husband/Wife Child Parent Unmarried Sibling Under 18 Years of Age	[Page 1] START HERE - Type or print in ink. See Instructions for information about eligibility and how to complete and file this application. The recipient of the T nonimmigrant classification is referred to as the principal applicant. His or her family member(s) is referred to as a derivative applicant. Form I-914, Supplement A, is to be completed by the principal applicant. Part 1. Family Member Relationship to You (the principal) (Select only one box in either Part 1. or Part 2.) 1. The family member that I am filing for is my: Husband/Wife Child Parent Unmarried Sibling Under 18 Years of Age
Page 1, PART B. Family member Relationship to Your Derivative	[Page 1] PART B. Family Member Relationship to Your Derivative The family member I am filing for is the adult or minor child of my derivative (my grandchild, my spouse's child, my niece or nephew, or my sibling) who faces a present danger of retaliation as a result of my escape from the severe form of trafficking in persons or my cooperation with law enforcement. Derivative's Adult OR Minor Child	[Page 1] Part 2. Family Member Relationship to Your Derivative 1. The family member I am filing for is the adult or minor child of one of the family members listed in Part 1., Item Number 1. who faces a present danger of retaliation as a result of my escape from the severe form of trafficking in persons or my cooperation with law enforcement and is the adult or minor (Select only one box in either Part 1. or Part 2.) Child of my spouse Child of my child (my grandchild) Child of my parent (my sibling over 18 years of age) Child of my unmarried sibling under 18 years of age (my niece or nephew) [deleted]
Page 1, PART C. General Information About You (the principal)	[Page 1] PART C. General Information About You (the principal) Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) A-Number (if any) Status of your Form I-914, Application for T Nonimmigrant Status: (Check one) Filing this Form I-914, Supplement A, concurrently Pending Approved	[Page 1] Part 3. General Information About You (the principal) 1. Your Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if any) 2. Date of Birth (mm/dd/yyyy) 3. Alien Registration Number (A-Number) [Page 2] 4. Status of your Form I-914, Application for T Nonimmigrant Status: (Select one) Filing this Form I-914, Supplement A, together Pending Approved
Pages 1-3, Part D. Information About Your Family Member (the derivative)	[Page 1] PART D. Information About Your Family Member (the derivative) Family Name (Last Name) Given Name (First Name) Middle Name Other Names Used (include maiden name/nickname) [new] Residence or Intended Residence in the U.S. - Street Number and Name Apt. Number City State ZIP Code [Page 2] Safe Mailing Address (if other than above) – [new] Street Number and Name Apt. Number C/O (in care of): City State/Province ZIP/Postal Code Home Telephone Number (with area code) Safe Daytime Telephone (with area code) E-mail Address (optional) A-Number U.S. Social Security Number Gender Male Female Marital Status: Single/Never Married Married Divorced Widowed [moved up] Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship Passport Number Place of Issuance Date of Issue (mm/dd/yyyy) Give the following information about your family member if he or she is currently in the United States. Place of Last Entry Date of Last Entry (mm/dd/yyyy) I-94 Number (Arrival-Departure Document) Current Immigration Status Give the following information about your family member if he or she has previously traveled to the United States. Place of Entry Date of Entry (mm/dd/yyyy) Date Authorized Stay Expired (mm/dd/yyyy) Immigration Status [Page 3] If your family member was previously married, list names of prior spouses and dates of termination of marriage. Documents such as divorce decrees or death certificates must be attached. Name of Former Spouse(s) Date Marriage Ended (mm/dd/yyyy) Where and How Marriage Ended If your family member is outside the United States, indicate the U.S. Consulate or inspection facility you want notified if this application is approved. Type of Office (Check one): Consulate Pre-Flight Inspection Port of Entry Office Address (City) U.S. State or Foreign Country Foreign Address Where You Want Notification Sent Has your family member ever been in immigration proceedings? Y/N If "Yes," what type of proceedings? (Check all that apply) Removal Date (mm/dd/yyyy) Exclusion Date (mm/dd/yyyy) Deportation Date (mm/dd/yyyy) Rescission Date (mm/dd/yyyy) Judicial Date (mm/dd/yyyy) Is your family member requesting an Employment Authorization Document? Y/N (If "Yes," submit Form I-765, Application for Employment Authorization Document with Form I-914, Supplement A, or separately.) NOTE: If your family member is living outside the United States, he or she is not eligible to receive employment authorization until he or she is lawfully admitted to the United States. Do not file Form I-765 for a family member living outside the United States.	[Page 2] Part 4. Information About Your Family Member (the derivative) 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if any) 2. Other Names Used Provide any other names you have used since birth, including aliases, maiden names, and nicknames. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Family Name (Last Name) [x2] Given Name (First Name) Middle Name (if any) 3. U.S. Physical Address or Intended U.S. Physical Address Street Number and Name Apt. Ste. Flr. [Number] City or Town State ZIP Code [Page 2] 4. Safe U.S. Mailing Address If you do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this application to your home address, you may provide an alternate safe mailing address. In Care Of Name Street Number and Name Apt./Ste./Flr. [Number] City or Town State ZIP Code [delete] 5. Alien Registration Number (A-Number) (if any) 6. USCIS Online Account Number 7. U.S. Social Security Number (SSN) (if any) 8. Gender or Sex Male Female Other [Page 3] 9. Marital Status Single/Never Married Married Divorced Widowed Annulled 10. If your family member was previously married, list names of prior spouses and dates of termination of marriage. Documents such as divorce decrees or death certificates must be attached. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. A. Name of Former Spouse Family Name (Last Name) Given Name (First Name) Middle Name B. Date Marriage Ended (mm/dd/yyyy) C. Where Marriage Ended City or Town State or Province Country D. How Marriage Ended Annulled Divorced Separated Widowed 11. Date of Birth (mm/dd/yyyy) 12. Place of Birth City or Town State or Province Country 13. Country of Citizenship or Nationality 14. Passport or Travel Document Number 15. Country That Issued Your Passport or Travel Document 16. Issue Date for Passport or Travel Document (mm/dd/yyyy) 17. Expiration Date for Passport or Travel Document (mm/dd/yyyy) [moved down] 18. Current Immigration Status 19. Is your family member currently living in the United States? Yes No [moved down] [moved up] [Page 4] 20. If you answered “Yes” to Item Number 19., give the following information about your family member if he or she is currently in the United States. A. Place of Last Entry City or Town State B. Date of Last Entry (mm/dd/yyyy) C. Form I-94 Arrival-Departure Record Number 21. If your family member is outside the United States, indicate the U.S. Consulate or inspection facility you want notified if this application is approved. A. Type of Office (Select one): Consulate Pre-Flight Inspection Port of Entry B. City or Town C. U.S. State or Foreign Country D. Foreign Address Where You Want Notification Sent Street Number and Name Apt./Ste./Flr. [Number] City or Town State ZIP Code Province Postal Code Country 22. Give the following information about your family member if he or she has previously traveled to the United States. A. Place of Entry City or Town State B. Date of Entry (mm/dd/yyyy) C. Date Authorized Stay Expired (mm/dd/yyyy) D. Immigration Status 23. Has your family member ever been in immigration court proceedings? Yes No 24. If you answered “Yes” to Item Number 23., what type of proceedings? (Select all that apply) A. Removal Date (mm/dd/yyyy) B. Exclusion Date (mm/dd/yyyy) C. Deportation Date (mm/dd/yyyy) D. Rescission Date (mm/dd/yyyy) E. Next Hearing Date (mm/dd/yyyy) [Page 5] 25. Is your family member requesting an Employment Authorization Document? Yes No (If you answered “Yes” to Item Number 25., submit Form I-765, Application for Employment Authorization Document, with Form I-914, Supplement A, or separately.) NOTE: If your family member is living outside the United States, he or she is not eligible to receive employment authorization until he or she is lawfully admitted to the United States. Do not file Form I-765 for a family member living outside the United States.
Pages 3-6, PART E. Process Information	[Page 3] PART E. Processing Information Answer the following questions about your family member. For the purposes of this application, if applicable, you must answer “Yes” to the following questions even if the records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told you that your family member no longer has a record. (If your answer is "Yes" to any one of these questions, explain on a separate sheet of paper. Answering "Yes" does not necessarily mean that your family member will be denied T nonimmigrant status.) 1. Has the family member for whom you are filing EVER: a. Committed a crime or offense for which he or she has not been arrested? Yes No b. Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and military officers) for any reason? Yes No c. Been charged with committing any crime or offense? Yes No d. Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)? Yes No e. Been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)? Yes No [Page 4] f. Received a suspended sentence, been placed on probation, or been paroled? Yes No g. Been in jail or prison? Yes No h. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action? Yes No i. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States? Yes No If the answer is “Yes” to any of the above questions, complete the following table. If you need more space, use a separate sheet of paper. [Table, 4 columns, 5 rows] Why was the family member for whom you are filing arrested, cited, detained, or charged? Date of arrest, citation, detention, charge (mm/dd/yyyy) Where was the family member for whom you are filing arrested, cited, detained, or charged? (City, State, Country) Outcome or disposition (e.g., no charges filed, charges dismissed, jail, probation, etc.) 2. Has the family member for whom you are filing: a. Engaged in prostitution or procurement of prostitution or does he or she intend to engage in prostitution or procurement of prostitution? Yes No b. EVER engaged in any unlawful commercialized vice, including but not limited to illegal gambling? Yes No c. EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally? Yes No d. EVER illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? Yes No 3. Has the family member for whom you are filing EVER committed, planned or prepared, participated in, threatened to, attempted to, or conspired to commit, gathered information for, or solicited funds for any of the following: a. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No b. Seizing or detaining, and threatening to kill, injure, or continue to detain, another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No c. Assassination? Yes No d. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No e. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No [Page 5] 4. Has the family member for whom you are filing EVER been a member of, solicited money or members for, provided support for, attended military training (as defined in section 2339D(c)(1) of title 18, United States Code) by or on behalf of, or been associated with an organization that is: a. Designated as a terrorist organization under section 219 of the Immigration and Nationality Act? Yes No b. Any other group of two or more individuals, whether organized or not, which has engaged in or has a subgroup which has engaged in: 1. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No 2. Seizing or detaining, and threatening to kill, injure, or continue to detain another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No 3. Assassination? Yes No 4. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No 5. Soliciting money or members or otherwise providing material support to a terrorist organization? Yes No 6. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No 5. Does the family member for whom you are filing intend to engage in the United States in: a. Espionage? Yes No b. Any unlawful activity, or any activity the purpose of which is in opposition, to control or overthrow of the Government of the United States? Yes No c. Solely, principally, or incidentally in any activity related to espionage or sabotage or to violate any law involving the export of goods, technology, or sensitive information? Yes No 6. Has the family member for whom you are filing EVER been or does he or she continue to be a member of the Communist or other totalitarian party, except when membership was involuntary? Yes No 7. Has the family member for whom you are filing, during the period of March 23, 1933, to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race, religion, nationality, membership in a particular social group, or political opinion? Yes No 8. Has the family member for whom you are filing EVER been present or nearby when any person was: a. Intentionally killed, tortured, beaten, or injured? Yes No b. Displaced or moved from his or her residence by force, compulsion, or duress? Yes No c. In any way compelled or forced to engage in any kind of sexual contact or relations? Yes No 9. a. Are removal, exclusion, rescission, or deportation proceedings pending against the family member for whom your are filing? Yes No b. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against the family member for whom your are filing? Yes No c. Has the family member for whom your are filing EVER been removed, excluded, or deported from the United States? Yes No d. Has the family member for whom your are filing EVER been ordered to be removed, excluded, or deported from the United States? Yes No e. Has the family member for whom your are filing EVER been denied a visa or denied admission to the United States? (If a visa was denied, explain why on a separate sheet of paper.) Yes No [Page 6] f. Has the family member for whom your are filing EVER been granted voluntary departure by an immigration officer or an immigration judge and failed to depart within the allotted time? Yes No 10. Has the family member for whom you are filing (or has any member of his or her family) EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: a. Acts involving torture or genocide? Yes No b. Killing any person? Yes No c. Intentionally and severely injuring any person? Yes No d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Yes No e. Limiting or denying any person's ability to exercise religious beliefs? Yes No 11. Has the family member for whom you are filing EVER: a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? Yes No b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Yes No 12. Has the family member for whom you are filing EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which he or she or any other persons used any type of weapon against any person or threatened to do so? Yes No 13. Has the family member for whom you are filing EVER assisted or participated in selling or providing weapons to any person who to his or her knowledge used them against another person, or in transporting weapons to any person who to his or her knowledge used them against another person? Yes No 14. Has the family member for whom you are filing EVER received any type of military, paramilitary, or weapons training? Yes No 15. Is the family member for whom you are filing under a final order or civil penalty for violating section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)? Yes No 16. Has the family member for whom you are filing EVER, by fraud or willful misrepresentation of a material fact, sought to procure, or procured, a visa or other documentation, for entry into the United States or any immigration benefit? Yes No 17. Has the family member for whom you are filing EVER left the United States to avoid being drafted into the U.S. Armed Forces? Yes No 18. Has the family member for whom you are filing EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement and not yet complied with that requirement or obtained a waiver of such? Yes No 19. Has the family member for whom you are filing EVER detained, retained, or withheld the custody of a child, having a lawful claim to U.S. citizenship, outside the United States from a U.S. citizen granted custody? Yes No 20. Does the family member for whom you are filing plan to practice polygamy in the United States? Yes No 21. Did the family member for whom you are filing enter the United States as a stowaway? Yes No 22. a. Does the family member for whom you are filing have a communicable disease of public health significance? Yes No b. Does the family member for whom you are filing have or has he or she had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of themselves or others? Yes No c. Is the family member for whom you are filing now or has he or she been a drug abuser or drug addict? Yes No	[Page 5] Part 5. Processing Information Answer the following questions about your family member. For the purposes of this application, if applicable, you must answer “Yes” to the following questions even if the records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney told you that your family member no longer has a record. (If your answer is “Yes” to any one of these questions, use the space provided in Part 9. Additional Information to explain your answer. Answering “Yes” does not necessarily mean that your family member will be denied T nonimmigrant status.) 1. Has the family member for whom you are filing EVER: A. Committed a crime or offense for which he or she has not been arrested? Yes No B. Been arrested, cited, or detained by any law enforcement officer (including Department of Homeland Security (DHS), former Immigration and Naturalization Service (INS), and military officers) for any reason? Yes No C. Been charged with committing any crime or offense? Yes No D. Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)? Yes No E. Been placed in an alternative sentencing or a rehabilitative program (for example, diversion, deferred prosecution, withheld adjudication, deferred adjudication)? Yes No F. Received a suspended sentence, been placed on probation, or been paroled? Yes No G. Been in jail or prison? Yes No H. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action? Yes No I. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States? Yes No If you answered “Yes” to any part of Item Number 1., complete the following table. If you need extra space to complete this section, use the space provided in Part 9. Additional Information to explain your answer. [Table, 4 columns, 5 rows] Why was the family member for whom you are filing arrested, cited, detained, or charged? Date of arrest, citation, detention, charge (mm/dd/yyyy) Where was the family member for whom you are filing arrested, cited, detained, or charged? (City or Town, State, Country) Outcome or disposition (for example, no charges filed, charges dismissed, jail, probation, etc.) [Page 6] 2. Has the family member for whom you are filing: A. Engaged in prostitution or procurement of prostitution or does he or she intend to engage in prostitution or procurement of prostitution? Yes No B. EVER engaged in any unlawful commercialized vice, including but not limited to illegal gambling? Yes No C. EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally? Yes No D. EVER illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? Yes No 3. Has the family member for whom you are filing EVER committed, planned or prepared, participated in, threatened to, attempted to, or conspired to commit, gathered information for, or solicited funds for any of the following: A. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No B. Seizing or detaining, and threatening to kill, injure, or continue to detain, another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No C. Assassination? Yes No D. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No E. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No 4. Has the family member for whom you are filing EVER been a member of, solicited money or members for, provided support for, attended military training (as defined in section 2339D(c)(1) of title 18, United States Code) by or on behalf of, or been associated with an organization that is: A. Designated as a terrorist organization under the Immigration and Nationality Act section 219? Yes No B. Any other group of two or more individuals, whether organized or not, which has engaged in or has a subgroup which has engaged in: (1) Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No (2) Seizing or detaining, and threatening to kill, injure, or continue to detain another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No (3) Assassination? Yes No (4) The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No (5) Soliciting money or members or otherwise providing material support to a terrorist organization? Yes No (6) The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No [Page 7] 5. Does the family member for whom you are filing intend to engage in the United States in: A. Espionage? Yes No B. Any unlawful activity, or any activity the purpose of which is in opposition, to control or overthrow of the Government of the United States? Yes No C. Solely, principally, or incidentally in any activity related to espionage or sabotage or to violate any law involving the export of goods, technology, or sensitive information? Yes No 6. Has the family member for whom you are filing EVER been or does he or she continue to be a member of the Communist or other totalitarian party, except when membership was involuntary? Yes No 7. Has the family member for whom you are filing, during the period of March 23, 1933, to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race, religion, nationality, membership in a particular social group, or political opinion? Yes No 8. Has the family member for whom you are filing EVER been present or nearby when any person was: A. Intentionally killed, tortured, beaten, or injured? Yes No B. Displaced or moved from his or her residence by force, compulsion, or duress? Yes No C. In any way compelled or forced to engage in any kind of sexual contact or relations? Yes No 9.A. Are removal, exclusion, rescission, or deportation proceedings pending against the family member for whom you are filing? Yes No B. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against the family member for whom you are filing? Yes No C. Has the family member for whom you are filing EVER been removed, excluded, or deported from the United States? Yes No D. Has the family member for whom you are filing EVER been ordered to be removed, excluded, or deported from the United States? Yes No E. Has the family member for whom you are filing EVER been denied a visa or denied admission to the United States? (If a visa was denied, use the space provided in Part 9. Additional Information to explain your answer.) Yes No F. Has the family member for whom you are filing EVER been granted voluntary departure by an immigration officer or an immigration judge and failed to depart within the allotted time? Yes No 10. Has the family member for whom you are filing (or has any member of his or her family) EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: A. Acts involving torture or genocide? Yes No B. Killing any person? Yes No C. Intentionally and severely injuring any person? Yes No D. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Yes No E. Limiting or denying any person's ability to exercise religious beliefs? Yes No 11. Has the family member for whom you are filing EVER: A. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? Yes No B. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Yes No [Page 8] 12. Has the family member for whom you are filing EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which he or she or any other persons used any type of weapon against any person or threatened to do so? Yes No 13. Has the family member for whom you are filing EVER assisted or participated in selling or providing weapons to any person who to his or her knowledge used them against another person, or in transporting weapons to any person who to his or her knowledge used them against another person? Yes No 14. Has the family member for whom you are filing EVER received any type of military, paramilitary, or weapons training? Yes No 15. Is the family member for whom you are filing under a final order or civil penalty for violating INA section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the INA)? Yes No 16. Has the family member for whom you are filing EVER, by fraud or willful misrepresentation of a material fact, sought to procure, or procured, a visa or other documentation, for entry into the United States or any immigration benefit? Yes No 17. Has the family member for whom you are filing EVER left the United States to avoid being drafted into the U.S. Armed Forces? Yes No [deleted] 18. Has the family member for whom you are filing EVER detained, retained, or withheld the custody of a child, having a lawful claim to U.S. citizenship, outside the United States from a U.S. citizen granted custody? Yes No 19. Does the family member for whom you are filing plan to practice polygamy in the United States? Yes No 20. Did the family member for whom you are filing enter the United States as a stowaway? Yes No 21.A. Does the family member for whom you are filing have a communicable disease of public health significance? Yes No B. Does the family member for whom you are filing have or has he or she had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of themselves or others? Yes No C. Is the family member for whom you are filing now or has he or she been a drug abuser or drug addict? Yes No
Pages 7-8, PART F. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature	[Page 7] PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-914 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. B. The interpreter named in Part G. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part H., [Fillable Field], prepared this application for me based only upon information I provided or authorized. Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any) Applicant's Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S. Citizenship and Immigration Services (USCIS) may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I authorize the release of any information from my record that USCIS needs to determine eligibility for the benefit I am seeking for the family member for whom I am applying, to investigate my claim, and to investigate fraudulent claims. I further authorize USCIS to release information to law enforcement agencies and prosecutors investigating or prosecuting crimes of trafficking or related crimes. I further authorize USCIS to release information to Federal, State, and local public and private agencies providing benefits, to be used solely in making determinations of eligibility for benefits pursuant to 8 USC 1641(c). I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant's Signature 6. Applicant's Signature (sign in ink) Date of Signature (mm/dd/yyyy) [Page 8] Signature of Derivative (your family member if physically present in the United States) (sign in ink) Date (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.	[Page 8] Part 6. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-914 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. B. The interpreter named in Part 7. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 8., [Fillable Field], prepared this application for me based only upon information I provided or authorized. [Page 9] Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any) Applicant's Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S. Citizenship and Immigration Services (USCIS) may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I authorize the release of any information from my record that USCIS needs to determine eligibility for the benefit I am seeking for the family member for whom I am applying, to investigate my claim, and to investigate fraudulent claims. I further authorize USCIS to release information to law enforcement agencies and prosecutors investigating or prosecuting crimes of trafficking or related crimes. I further authorize USCIS to release information to Federal, State, and local public and private agencies providing benefits, to be used solely in making determinations of eligibility for benefits pursuant to 8 USC 1641(c). I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant's Signature 6. Applicant's Signature Date of Signature (mm/dd/yyyy) Applicant’s Phone Number (if any) Applicant’s Safe Phone Number 7. Signature of Derivative (your family member if physically present in the United States) Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.
Page 8, PART G. Interpreter’s Contact Information, Certification, and Signature	[Page 8] PART G. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part F., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature (sign in ink) Date of Signature (mm/dd/yyyy)	[Page 8] Part 7. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part 6., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)
Page 9, PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 9] PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) Preparer's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer's Statement 7. A. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. B. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8. Preparer's Signature (sign in ink) Date of Signature (mm/dd/yyyy)	[Page 9] Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) Preparer's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer's Statement 7. A. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. B. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8. Preparer's Signature Date of Signature (mm/dd/yyyy)
New		[Page 10] Part 9. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1. Family Name (Last Name) [Auto-populated field] Given Name (First Name) [Auto-populated field] Middle Name [Auto-populated field] 2. A-Number [Auto-populated field] 3. A. Page Number B. Part Number C. Item Number D. [Fillable field] 4. A. Page Number B. Part Number C. Item Number D. [Fillable field] 5. A. Page Number B. Part Number C. Item Number D. [Fillable field] 6. A. Page Number B. Part Number C. Item Number D. [Fillable field]

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